Our August On the Road took us to the heart of Texas. While some might suggest my timing was off visiting in the heat of summer, it was the perfect time to experience the warmth and compassion exemplified by the efforts of the team at St. David’s HealthCare. St. David’s healthcare has taken on a system-wide effort across its 6 acute hospitals and rehabilitation hospital; one that has been driven by the system’s over 7500 employees.

My visit, hosted by CJ Merrill, Associate VP of Service Excellence (pictured below from left to right with Collette, Nurse Manager, Holly Johnson, Unit Director and CJ Merrill), included time interacting with Executive and Nurse Leadership and a special opportunity to engage with the system’s Service Excellence Champion team. The foundation of the effort at St. David’s reveals a common and emerging theme in conversations on improving experience; that culture is a central component of patient experience success. "The opportunity in every encounter is to create memorable moments,” offered Merrill. While like many organizations, St. David’s has worked hard to implement some of the central tactics shown to add value to service such as hourly and leadership rounding, consistent use of message boards, service recovery, etc., it is their willingness to create a strong cultural foundation and ensure alignment across the system that allows them to excel on their journey to create truly memorable moments.

ICARE – Much More than an Acronym

The story of the effort at St. David’s is about a transition of culture. It was about an effort over the last few years to change from a focus on compliance to one of shared commitment. It was reinforced by a move in intention beyond quality of care to quality of the total patient experience. Through alignment of efforts and a central Service Excellence team to support, reinforce, communicate and share ideas, the organization overall made a significant shift.

Fundamental to this transition was a structured effort to refocus the organization on key ideas that would ensure a consistent and effective delivery of the care experience. The first elements of this effort are key service values and a central mission. While many organizations have adopted and implemented values based on their reinforcement as a core management principle, St. David’s has taken something that often becomes just words posted on a wall and gave it life. While the values represented by ICARE (Integrity, Compassion, Accountability, Respect, and Excellence) may sound familiar to some, they have become a 365-day-a-year effort to drive a culture of care and service in the system. In conjunction with St. David’s mission, "To provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride”, the values create an actual operating framework for engaging staff across the system.

This infrastructure for accountability is well defined and executed with consistency. The process includes a few central actions. Each week one of the five values is identified as the central focus for that week (running Sunday to Saturday). On the Friday before a weekly email is distributed which includes the overview of the process and an individual content item to be discussed each day of the week ahead.

You may be asking what is the content used for? St. David’s has implemented a process called Daily Round Ups (similar in idea to huddles other organization’s might use). These Round Ups have far greater structure than typical huddles as they are framed to be consistent and reinforcing of the key messages around the culture they are trying to create. The Round Up is a short daily gathering in a unit, department or office. They happen on all shifts. The purpose is to engage the team in discussion about the value of the week, reinforcing the central aspects of culture, reviewing operational items and restating the mission of the organization.

The distinction here is that the team at St. David’s has created an accountability system and a unique piece of content for every day of the year. These include quotes, ideas for practice or other important pieces of information. The Round Ups are all structured following the same steps helping the local team lead, director, etc. to facilitate the process with ease. The Round Up incorporates the following steps and is targeted to take no more than 5 minutes:

Team members are engaged in the value of the week and discuss the value around three central areas of focus and associated questions on:

Defining the culture – e.g. What does Integrity mean to you?

Living the culture – e.g. How will you apply this value today?

Managing the culture – e.g. How can we keep each other accountable? Who can we recognize for demonstrating the value today?

Usually a patient story is identified or situation discussed to reinforce these themes in the moment

Key operational items are discussed to ensure the team is on the same page and hearing the same thing

The mission statement is reviewed/recited

I had the chance to see a Round Up in action at St. David’s Medical Center and was struck by the intent and focus with which the team members on the unit engaged. The time for the Round Up was called and almost instantaneous people from across the unit appeared and gathered around the nurses’ station. The discussion exemplified the understanding and importance of the value of the week, they quickly identified and planned for the key issues of the shift and to close it was powerful to see a new nurse just getting started on the floor offering to recite the mission statement to the quiet cheers of her colleagues. The unit leader offered additional kudos and shared some information and then as quickly as they came they were back to their patients.

As significant as this one encounter was it is the fact that there is alignment and support across the system for consistency in this effort that is significant. The effort to instill the values, the mission and fundamentally the culture of St. David’s is reviewed, reinforced and reinvigorated daily. As Kristin, one of the unit supervisors shared with me, "We cannot and will not have excellence, if we don't do it all the time.” It is clear that the commitment to focus and consistent execution has been a central driver in building a true culture of service at St. David’s.

This commitment to execution is supported by a structure of accountability. This is seen not only in providing the content to share weekly, but also in additional ways. The monthly gathering of the Service Excellence Champions (more below), site visits from the service excellence team to observe and engage in the process and ultimately quarterly service reviews all create a network of reinforcement. "Culture is not just something you build overnight, noted Lisa Doyle, Sr. VP of Human Resources, "we must continue to work on it each and every day.”

The Power of ‘Uniform’ity

While the infrastructure of accountability for reinforcing culture and expectations through Round Ups was impressive as a process, consistency and care was also conveyed in a very powerful visual manner. The St. David’s system has adopted a unique and very impactful standard by creating uniforms for all major roles throughout the system. This is not the typical uniform policy where staff of one type wears one color, while those in another role wear a different color. The uniform effort at St. David’s was visually stunning and (at least for my weathered healthcare perspective) allowed for a sense of structure and calm in what is typically nothing less than a typically chaotic environment.

While I know this creates controversy in some organizations and seems too much to tangle with in others, the effort at St. David’s reinforces the very message around consistency in culture that is part of Round Ups. The uniforms are not just assigned a color by role, but also clearly embroidered with the individual’s role spelled out. This does not only occur in bedside roles, but all clinical and support roles have a uniform that fits their purpose and allows them to be easily identified from registered nurses to unit clerks, PT to food service to engineering. This consistency was crisp, clear and as I observed allowed patients and families to quickly identify staff, easing confusion and/or fear and helping streamline engagements; ultimately putting care and service first.

The following video from St. David’s provides a short and compelling overview (and case) for why this policy is central to the system’s mission overall. Delivering with consistency is not only in words and actions, but in what patients and families see. This idea is one that brings great value to the overall interactions with patients and families; it also creates greater connection and reinforces the nature of collaboration across the system

Collaboration for Collective Success

In my healthcare career I have always been amazed by the level of competition in markets, sometimes at the cost of potential collaborative improvements. This is not much different in organizations with multiple facilities in the same market where competition trumps collaboration at what might be much bigger costs. While the team at St. David’s would not claim all competition has vanished and in fact believe healthy competition is good, they have harnessed the power of a systemic perspective and collaborative action to drive overall outcomes.

This is exemplified by the collective efforts of the Service Excellence Champions (SEC) team and by the ongoing learning efforts central to supporting performance excellence across the system. I had the opportunity to spend time with the SEC as they offered a collective overview of the overall experience efforts. The team was comprised of Senior Executives from each of the facilities in the system. What struck me as much as the amazing efforts taking place (and many of which I described above), was that the team was genuinely committed to shared-learning and exemplified the power of alignment in executing with success. The consistency with which Round Ups are performed, the reinforcing of uniform policy or the piloting and eventual rollout of new tactics all rest on this group’s collective efforts.

Each member reinforced the message I saw in the facilities. There was a commitment to help employees know, connect to and express the St. David’s mission. There was a commitment to live the values and help the staff understand how their own role contributed to supporting that culture. There was a commitment to skills and leadership development at all levels. In fact the system has its own extensive Institute for Learning.

This focus on learning plays a key role in the system’s overall success, from a shared orientation process so that all new employees regardless of role have the same grounding in the organizational expectations, to formal leadership development programs that not only develop leadership strength, but operational consistency as well. In addition, the learning process incorporates an innovative Skills Lab process where through simulation, observation and feedback members of the St. David’s system are being trained on exceptional service delivery (you can actually learn more about this program as one of the breakout sessions at Patient Experience Conference 2013).

The bottom line is that St. David’s has made a commitment to a plan, and then where many others fall short, they made a commitment to support that plan through shared information and learning, ongoing development and collaboration. As one member of the SEC said to me as we closed our meeting, "Our job is simple if we do it right, it is to perpetuate these ideas and share them system wide. If we do that effectively, the results will come.” From my sense of the consistency in execution and expression of St David’s pride the results are coming and as if on cue another SEC member added, "We know we are not ‘there’ yet, but we should never stop doing what it takes.”

Doing what it Takes

The phrase stuck with me as it was a true representation of the persistence and focus I saw from the efforts C.J. Merrill shared, the SEC discussed and the staff in the facilities of St. David’s exemplified in their actions. As I wrapped up my visit I had the chance to pose one final question to the leaders on the SEC. I kept it broad, yet challenging, as I believe the shared insights of this group would be valuable in addition to the effective practices I had seen. What were the nuggets they would share or words of advice for others that they believed supported their success to date? The responses were concise and thoughtful and I believe offer an important lesson to all taking on the patient experience challenge. They included:

"You must believe, you must know this is the right thing to do” (especially as a leader you must decide, am I in or out).

"Remain faithful to what it is you set out to do.”

"There must be a ‘stick-to-it-ness’ and a willingness to see it through.”

"Success only comes if you build in accountability and it is accountability that leads to consistency.”

"You need to work tirelessly to connect suggested actions, programs or other efforts to the ‘why’. If you can’t, then why are you doing it?”

Lastly a CNO in the group sat back with a smile, the rest of the team turned to her anticipating her comment and she shared, "At the end of the day it takes courage, leadership courage, to make this a priority.”

It was in those few words that my visit may best me summarized. St. David’s as a system showed incredible courage, from those trying to drive a cultural transition to service through simple, but powerful process, to those gathering regularly to test and share ideas, to the leadership making this a priority and ultimately to the staff who energetically grabbed the reigns in their departments, on their units or in their practices and committed to the mission - to provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride. It was that pride I saw on the floors of St. David’s Medical Center and in the eyes of the leaders on the SEC. Through commitment, focus and consistent effort it is clear the team at St. David’s will continue on its path to ensure positive memorable moments for the patients, families and community they serve.

For questions about the effort at St. David’s HealthCare, you can contact:CJ Merrill, MSN, RNAVP Service ExcellenceCJ.Merrill@stdavids.com